Telemedicine Cuts Deaths in ICU

Action Points

Explain that a meta-analysis of 13 studies showed that using telemedicine in intensive care units significantly reduced ICU mortality and length of stay, but did not lead to an overall decrease in inhospital mortality or length of stay.

Note that all of the studies were before-and-after studies with little information available about differences in disease severity.

Telemedicine in the ICU lowers mortality and length of stay in intensive care, but has no effect on these parameters in the rest of the hospital, researchers said.

In a meta-analysis, use of telemedicine reduced ICU mortality by 20% and shortened the average length of stay in the ICU by 1.26 days, Lance Brendan Young, PhD, of the Iowa City Veterans Affairs Medical Center, and colleagues reported in the March 28 issue of Archives of Internal Medicine.

But it wasn't linked to any improved outcomes in hospital mortality or length of stay.

Remote coverage of intensive care units is rapidly being adopted, largely to compensate for a lack of on-site intensivist expertise, theresearchers wrote.

ICU telemedicine involves a combination of videoconferencing technology, telemetry, and electronic medical records in order to allow off-site intensivists and critical care nurses to assist in the treatment of critically ill patients.

Yet the effects of its rapid adoption on patient outcomes remain unclear, the researchers said.

So Young and colleagues conducted a meta-analysis to examine the impact of ICU telemedicine on mortality and length of stay.

Their review of the literature from 1950 to 2010 found 13 suitable studies conducted at 35 ICUs around the country, which were published between 2004 and 2010. The studies involved a total of 41,374 patients, and all had a before-and-after design.

They found that telemedicine in the ICU was associated with a significant reduction in ICU mortality (OR 0.80, 95% CI 0.66 to 0.97, P=0.02).

It was also associated with a reduction in ICU length of stay, with a mean difference of 1.26 days (P=0.01).

However, telemedicine wasn't associated with a reduction in inhospital mortality or overall length of stay, the researchers said.

"Tele-ICU care might reduce the mortality for ICU patients while the patients are still in the ICU, but this benefit could be eroded once patients are transferred to the floor," they wrote.

With regard to the improved mortality in the ICU, the researchers said that it could be due to changes in triage and medical decision-making, such that it may lead to changes in decisions as to who gets admitted to the ICU in the first place.

In terms of shorter length of ICU stay, it could be attributable to the fact that around-the-clock oversight leads to a greater willingness to transfer patients out of the ICU on weekends and evenings, they said.

They also cautioned, however, that more studies reported ICU mortality than inhospital deaths, which could mean reduced statistical power for the latter parameter.

Their review was also limited by the strength of the studies included. The most visible shortcoming, they said, was the lack of consistent measurement, reporting, and adjustment for disease severity.

Other limitations included the before-and-after study design, lack of standardized use of telemedicine (daily versus nights/weekends versus as needed), aggregate rather than individual hospital data, and rare cost data, so the researchers couldn't draw meaningful conclusions about cost-effectiveness of telemedicine in the ICU.

They concluded that the results "highlight the need for more rigorous evaluation of the tele-ICU coverage."

In an accompanying editorial, Jeremy Kahn, MD, of the University of Pittsburgh, agreed that the analysis provides an opportunity to "reframe and refocus research into the efficacy of ICU telemedicine."

He called for more multicenter, randomized controlled trials to establish the true risks and benefits with regard to both ICU and inhospital mortality and length of stay.

Kahn also added that the study should spur physicians to revisit the goals of ICU telemedicine itself -- not just seeing it as an option for patient safety but rather as an effectiveness tool if it proved to be more effective.

The study was supported by the Department of Veterans Affairs.

The researchers reported no conflicts of interest.

Kahn received a grant from the Agency for Healthcare Research and Quality to determine a research agenda for ICU telemedicine.

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